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Dutch Consensus Paper: A Consensus View on the Place of Neurostimulation Within the Treatment Arsenal of Five Reimbursed Indications for Neurostimulation in The Netherlands. Neuromodulation 2022; 25:1059-1063. [PMID: 35562262 DOI: 10.1016/j.neurom.2022.02.232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION After an interpretation trajectory, the Dutch Quality of Healthcare Institute recommended that for five indications, spinal cord stimulation, dorsal root ganglion stimulation, or occipital nerve stimulation, together referred to as neurostimulation, can be considered effective and be reimbursed in the Netherlands. These five indications are the well and largely studied, accepted neurostimulation indications in scientific literature. As an extension of this, all the scientific societies involved in the Netherlands were required to reach a consensus about the diagnosis and treatment of these five formulated indications to describe the place of neurostimulation within the treatment algorithm. This article describes the development process and content of the consensus paper. MATERIALS AND METHODS A scientific committee, consisting of three anesthesiologists/pain physicians (one of whom acted as the working group's chair), a neurosurgeon, a neurologist, a rehabilitation physician, and three nurse practitioners, participated. A quality advisor of the Knowledge Institute of the Dutch Federation of Medical Specialists supported the committee. The committee participated on behalf of their various scientific and professional societies. Three sessions were organized during which the place of neurostimulation in the treatment algorithm of the five relevant indications was discussed extensively. A narrative literature review and experts' opinions formed the basis of decision-making in the process. RESULTS For all five diagnoses, general and diagnosis-specific treatment requirements, conservative treatments, and minimally invasive treatments are listed. These treatments should be considered in the chronic pain management algorithm before eventually proceeding to neurostimulation. DISCUSSION/CONCLUSION The content of this consensus view was discussed and compared with other literature on cost-effectiveness and the place in the algorithm of treating chronic pain. This Dutch consensus paper could ultimately contribute to the maintenance or expansion of neurostimulation and the reimbursement.
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Jung HH, Koh CS, Park M, Kim JH, Woo HN, Lee H, Chang JW. Microglial deactivation by adeno-associated virus expressing small-hairpin GCH1 has protective effects against neuropathic pain development in a spinothalamic tract-lesion model. CNS Neurosci Ther 2021; 28:36-45. [PMID: 34845843 PMCID: PMC8673712 DOI: 10.1111/cns.13751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 12/24/2022] Open
Abstract
AIMS Neuropathic pain after spinal cord injury is one of the most difficult clinical problems after the loss of mobility, and pharmacological or neuromodulation therapy showed limited efficacy. In this study, we examine the possibility of pain modulation by a recombinant adeno-associated virus (rAAV) encoding small-hairpin RNA against GCH1 (rAAV-shGCH1) in a spinal cord injury model in which neuropathic pain was induced by a spinothalamic tract (STT) lesion. METHODS Micro-electric lesioning was used to damage the left STT in rats (n = 32), and either rAAV-shGCH1 (n = 19) or rAAV control (n = 6) was injected into the dorsal horn of the rats at the same time. On postoperative days 3, 7, and 14, we evaluated neuropathic pain using a behavioral test and microglial activation by immunohistochemical staining. RESULTS A pain modulation effect of shGCH1 was observed from postoperative days 3 to 14. The mechanical withdrawal threshold was 13.0 ± 0.95 in the shGCH1 group, 4.3 ± 1.37 in the control group, and 3.49 ± 0.85 in sham on postoperative day 3 (p < 0.0001) and continued to postoperative day 14 (shGCH1 vs. control: 11.4 ± 1.1 vs. 2.05 ± 0.60, p < 0.001 and shGCH1 vs. sham: 11.4 ± 1.1 vs. 1.43 ± 0.54, p < 0.001). Immunohistochemical staining of the spinal cord dorsal horn showed deactivation of microglia in the shGCH1 group without any change of delayed pattern of astrocyte activation as in STT model. CONCLUSIONS Neuropathic pain after spinal cord injury can be modulated bilaterally by deactivating microglial activation after a unilateral injection of rAAV-shGCH1 into the dorsal horn of a STT lesion spinal cord pain model. This new attempt would be another therapeutic approach for NP after SCI, which once happens; there is no clear curative options still now.
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Affiliation(s)
- Hyun Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science and Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Chin Su Koh
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Minkyung Park
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science and Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hyun Kim
- Department of Microbiology, University of Ulsan College of Medicine, Seoul, Korea.,Bio-Medical Institute of Technology, University of Ulsan College of Medicine, Seoul, Korea
| | - Ha-Na Woo
- Bio-Medical Institute of Technology, University of Ulsan College of Medicine, Seoul, Korea.,Department of Biochemistry & Molecular Biology, University of Ulsan College of Medicine, Seoul, Korea
| | - Heuiran Lee
- Bio-Medical Institute of Technology, University of Ulsan College of Medicine, Seoul, Korea.,Department of Microbiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science and Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Ranjan M, Kumar P, Konrad P, Rezai AR. Finding Optimal Neuromodulation for Chronic Pain: Waves, Bursts, and Beyond. Neurol India 2020; 68:S218-S223. [PMID: 33318354 DOI: 10.4103/0028-3886.302465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Spinal cord stimulation (SCS) has emerged as state-of-the-art evidence-based treatment for chronic intractable pain related to spinal and peripheral nerve disorders. Traditionally delivered as steady-state, paraesthesia-producing electrical stimulation, newer technology has augmented the SCS option and outcome in the last decade. Objective To present an overview of the traditional and newer SCS waveforms. Materials and Methods We present a short literature review of SCS waveforms in reference to newer waveforms and describing paraesthesia-free, high frequency, and burst stimulation methods as well as advances in waveform paradigms and programming modalities. Pertinent literature was reviewed, especially in the context of evolution in the waveforms of SCS and stimulation parameters. Results Conventional tonic SCS remains one of the most utilized and clinically validated SCS waveforms. Newer waveforms such as burst stimulation, high-frequency stimulation, and the sub-perception SCS have emerged in the last decades with favorable results with no or minimal paraesthesia, including in cases otherwise intractable to conventional tonic SCS. The recent evolution and experience of closed-loop SCS is promising and appealing. The experience and validation of the newer SCS waveforms, however, remain limited but optimistic. Conclusions Advances in SCS device technology and waveforms have improved patient outcomes, leading to its increased utilization of SCS for chronic pain. These improvements and the development of closed-loop SCS have been increasingly promising development and foster a clinical translation of improved pain relief as the years of research and clinical study beyond conventional SCS waveform come to fruition.
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Affiliation(s)
- Manish Ranjan
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University
| | - Pranab Kumar
- Department of Anaesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto
| | - Peter Konrad
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University
| | - Ali R Rezai
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University
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Sclafani J, Leong M, Desai MJ, Mehta N, Sayed D, Singh JR. Conventional versus High-Frequency Neuromodulation in the Treatment of Low Back Pain Following Spine Surgery. PM R 2020; 11:1346-1353. [PMID: 31648418 DOI: 10.1002/pmrj.12270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022]
Affiliation(s)
| | - Michael Leong
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - Mehul J Desai
- International Spine, Pain & Performance Center, George Washington University, Washington, DC
| | - Neel Mehta
- Departmet of Anesthestiology, Division of Pain Medicine, Weill Cornell Medicine, New York, NY
| | - Dawood Sayed
- Department of Anesthesiology, Medical Director of Spine Center, University of Kansas, Kansas City, KS
| | - Jaspal R Singh
- Department of Rehabilitation Medicine, Weill Cornell Center for Comprehensive Spine Care, Weill Cornell Medicine, New York, NY
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Yearwood T, De Ridder D, Yoo HB, Falowski S, Venkatesan L, Ting To W, Vanneste S. Comparison of Neural Activity in Chronic Pain Patients During Tonic and Burst Spinal Cord Stimulation Using Fluorodeoxyglucose Positron Emission Tomography. Neuromodulation 2019; 23:56-63. [PMID: 31039294 DOI: 10.1111/ner.12960] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/09/2019] [Accepted: 03/19/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Burst spinal cord stimulation (SCS) is a novel stimulation paradigm that seems to provide better pain relief compared to the classic tonic SCS with minimal paresthesia sensation. Based on source localized electroencephalography and clinical data, it has been proposed that burst stimulation as defined by Dirk De Ridder exerts this greater effect by not only modulating the lateral and the descending pain-inhibitory pathways (similar to tonic SCS) but also modulating the medial pain pathway, which encodes the affective, motivational aspects of pain. MATERIAL AND METHODS The current study evaluates the supraspinal differences between burst and tonic stimulation with another functional imaging technique, namely fluorodeoxyglucose positron emission tomography (FGD-PET) scanning, in seven patients, who underwent both burst and tonic SCS, to confirm this notion of medial pain pathway modulation. RESULTS The results of the current FGD-PET study show that burst stimulation, in contrast to tonic stimulation, indeed modulates the dorsal anterior cingulate cortex (i.e., medial pain pathway) more than tonic stimulation. DISCUSSION Our data suggest an inherent difference in the central neural mechanisms during burst and tonic stimulation, which could potentially alter the patient's perception of pain. CONFLICT OF INTEREST Dr. Yearwood, Dr. De Ridder, Dr. Falowski, and Dr. Vanneste are the consultants of Abbott. Dr. Venkatesan is an employee of Abbott. Hye Bin Yoo and Dr. Wing Ting To have no conflicts of interest to report.
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Affiliation(s)
| | - Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, New Zealand
| | - Hye Bin Yoo
- Lab for Clinical & Integrative Neuroscience, School of Behavioral and Brain Sciences, The University of Texas at Dallas, TX, USA
| | | | | | - Wing Ting To
- Lab for Clinical & Integrative Neuroscience, School of Behavioral and Brain Sciences, The University of Texas at Dallas, TX, USA
| | - Sven Vanneste
- Lab for Clinical & Integrative Neuroscience, School of Behavioral and Brain Sciences, The University of Texas at Dallas, TX, USA.,School of Psychology & Global Brain Health Institute, Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
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Skaribas IM, Peccora C, Skaribas E. Single S1 Dorsal Root Ganglia Stimulation for Intractable Complex Regional Pain Syndrome Foot Pain After Lumbar Spine Surgery: A Case Series. Neuromodulation 2018; 22:101-107. [DOI: 10.1111/ner.12780] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 02/17/2018] [Accepted: 02/20/2018] [Indexed: 12/28/2022]
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Maher DP, Martins YC, Doshi T, Bicket M, Zhang K, Hanna G, Ahmed S. Neuropathic Pain Medication Use Does Not Alter Outcomes of Spinal Cord Stimulation for Lower Extremity Pain. Neuromodulation 2017; 21:106-113. [PMID: 28980364 DOI: 10.1111/ner.12697] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/30/2017] [Accepted: 08/08/2017] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Spinal cord stimulation (SCS) for the treatment of lower extremity pain is believed to the result of increased activity in the descending inhibitory and decreased activity in the ascending excitatory tracts. Evidence suggests that the analgesia afforded by SCS may be altered using certain neuropathic pain medications that also modulate neurotransmitters in these sensory tracts. We hypothesize that neuropathic pain medications may alter the response to SCS therapy. METHODS One hundred and fifteen subjects undergoing SCS therapy for lower extremity pain were retrospectively examined. The pharmacologic profile, including stable use of neuropathic and opioid medications, were recorded. Three separate logistic regression models examined the odds ratio of primary outcomes; a successful SCS trial, a 50% decrease in pain or a 50% reduction in opioid use one year after implant. RESULTS Neither the use of opioids or neuropathic pain medications were associated with changes in the odds of a successful SCS trial or a 50% pain reduction. A higher dose of chronic opioids use prior to a trial was associated with greater odds of having a 50% reduction in opioid use following implant. OR 1.02, 95% CI 1.01-1.02, p-value < 0.01). CONCLUSIONS The use of neuropathic pain medications did not change the odds of either a successful SCS trial, or of experiencing a 50% reduction in pain at one year. The association between higher opioid doses and greater odds of a 50% reduction in opioid use may be the reflective of SCS's ability to reduce opioid reliance in chronic pain patients.
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Affiliation(s)
- Dermot P Maher
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital and Health System, Baltimore, MD, USA
| | - Yuri Chaves Martins
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tina Doshi
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital and Health System, Baltimore, MD, USA
| | - Mark Bicket
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital and Health System, Baltimore, MD, USA
| | - Kui Zhang
- Department of Mathematical Sciences, Michigan Technological University, Houghton, MI, USA
| | - George Hanna
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Shihab Ahmed
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Chang Chien GC, Mekhail N. Alternate Intraspinal Targets for Spinal Cord Stimulation: A Systematic Review. Neuromodulation 2017; 20:629-641. [PMID: 28160397 DOI: 10.1111/ner.12568] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/14/2016] [Accepted: 11/14/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Conventional dorsal column spinal cord stimulation (SCS) provides less than optimal pain relief for certain pain syndromes and anatomic pain distributions. Practitioners have sought to treat these challenging therapeutic areas with stimulation of alternate intraspinal targets. OBJECTIVE To identify and systematically review the evidence for the value neuromodulating specific neuronal targets within the spinal canal to achieve relief of chronic pain. METHODS A systematic literature search was conducted using PubMed for clinical trials published from 1966 to March 1, 2015 to identify neurostimulation studies that employed non-dorsal column intraspinal stimulation to achieve pain relief. Identified studies on such targeted intraspinal stimulation were reviewed and graded using Evidence Based Interventional Pain Medicine criteria. RESULTS We found a total of 13 articles that satisfied our search criteria on targeted, non-dorsal column intraspinal stimulation for pain. We identified five studies on neurostimulation of the cervicomedullary junction, six studies on neurostimulation of the dorsal root ganglion, two studies on the neurostimulation of the conus medullaris, unfortunately none was found on intraspinal nerve root stimulation. LIMITATIONS The limitations of this review include the relative paucity of well-designed prospective studies on targeted SCS. CONCLUSIONS Clinical use of intraspinal neurostimulation is expanding at a very fast pace. Intraspinal stimulation of non-dorsal column targets may well be the future of neurostimulation as it provides new clinically significant neuromodulation of specific therapeutic targets that are not well or not easily addressed with conventional dorsal column SCS. In addition, they may avoid undesired stimulation induced paraesthesia, particularly in non-painful areas of the body.
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Affiliation(s)
- George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA.,Center for Regenerative Medicine, Southern California University of Health Sciences, Whittier, CA, USA
| | - Nagy Mekhail
- Evidence Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
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Abstract
Upper extremity neuropathic pain states greatly impact patient functionality and quality of life, despite appropriate surgical intervention. This article focuses on the advanced therapies that may improve pain care, including advanced treatment strategies that are available. The article also surveys therapies on the immediate horizon, such as spinal cord stimulation, peripheral nerve stimulation, and dorsal root ganglion spinal cord stimulation. As these therapies evolve, so too will their placement within the pain care algorithm grounded by a foundation of evidence to improve patient safety and management of patients with difficult neuropathic pain.
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Affiliation(s)
- Jason E Pope
- Summit Pain Alliance, 392 Tesconi Court, Santa Rosa, CA 95401, USA.
| | - David Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, PA 15143, USA
| | | | - Timothy Deer
- Center for Pain Relief, Charleston, WV 25304, USA
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